Stylized cesarean section incision closed with sutures.

Cesarean Closure: Why Suture Remains the Gold Standard for Skin Incisions

Theo Raines monogram
Theo Raines in Health & Wellness October 2026 • 4 min read.

"Despite advancements in surgical techniques, absorbable suture continues to lead in cesarean skin closure due to its superior outcomes and patient satisfaction."


Cesarean delivery (CD), one of the most common surgical procedures performed worldwide, has seen numerous advancements in techniques aimed at improving outcomes and patient experience. Among these advancements, the method of skin closure remains a critical aspect of the procedure. With over 1,000 randomized controlled trials (RCTs) dedicated to the technical nuances of cesarean delivery, the choice between sutures, staples, glue, and other methods has been a topic of extensive research and debate.

In a recent mini-commentary, experts weighed in on a 2018 randomized clinical trial that compared absorbable subcuticular staples versus suture for cesarean closure. This commentary sheds light on why suture continues to be regarded as the gold standard for skin incision closure in cesarean deliveries, despite the introduction of newer methods.

This article delves into the evidence supporting the use of absorbable sutures for skin closure in cesarean sections. We will explore the comparative studies, the advantages of suture over other methods such as staples and glue, and the implications for patient outcomes and satisfaction. By examining the current research and expert opinions, we aim to provide a comprehensive understanding of why suture remains the preferred choice in modern obstetrical practice.

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Cesarean Delivery Today

Cesarean section, also called C-section, cesarean, or caesarean delivery, delivers one or more babies through an incision in the mother's abdomen. It may be performed when vaginal delivery could put the mother or child at risk, including situations such as obstructed labor or twin pregnancy. Cesarean delivery has become the most frequently performed major surgical procedure worldwide, with nearly 29 million births each year.

A Surgical Standard

Cesarean delivery generally involves making an incision through the abdominal wall and uterus to deliver the baby. The appropriate surgical approach can depend on the clinical circumstances, and the procedure is typically used when complications make vaginal delivery unsafe. As with any major operation, decisions about technique and closure require individualized clinical judgment.

From Last Resort to Common Procedure

Cesarean delivery has changed substantially over time, moving from an operation of last resort to a routine component of modern obstetric care. Advances in anesthesia, surgical technique, and perioperative care have contributed to improved safety. This history also illustrates why cesarean delivery remains both a major medical procedure and an important subject of ongoing evaluation.

Why Suture Holds Its Ground: Evidence from Research

Stylized cesarean section incision closed with sutures.

Numerous studies have compared absorbable suture to nonabsorbable metal staples for skin closure following cesarean delivery. A meta-analysis of 12 RCTs, involving 3,112 women, demonstrated that suture closure is associated with fewer wound complications, particularly wound separation. This finding underscores the reliability and effectiveness of suture in promoting better healing outcomes.

Beyond the reduced risk of wound complications, suture closure offers additional benefits that contribute to its status as the gold standard. These include improved cosmesis and increased patient satisfaction. Studies have shown that women who undergo suture closure report higher levels of satisfaction with the aesthetic outcome of their scars compared to those who receive metal staple closure.

  • Reduced Wound Complications: Meta-analyses show lower rates of wound separation with suture closure.
  • Improved Cosmesis: Suture closure leads to more aesthetically pleasing scar appearance.
  • Increased Patient Satisfaction: Women report higher satisfaction levels with suture closure outcomes.
  • Gold Standard Recommendation: Current guidelines favor absorbable suture for skin closure due to robust evidence.
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Ongoing Clinical Evaluation

Current discussion of cesarean care continues to examine how surgical technique, anesthesia, perioperative management, and recovery can be optimized. Research and reviews may also consider the broader clinical and psychological effects of cesarean delivery. Because practices and evidence can change, conclusions about specific closure methods should be interpreted in light of contemporary clinical guidance.

Recognizing Surgical Limits

The American College of Obstetricians and Gynecologists defines cesarean birth as delivery through surgical incisions made in the belly and uterus. This definition underscores that cesarean delivery is an operative intervention rather than a minor variation of vaginal birth. Its risks, recovery demands, and potential complications therefore need to be weighed against the circumstances that made surgical delivery necessary.

Comparing Closure Choices

Comparisons among skin-closure methods should account for more than appearance alone. Clinicians may consider wound integrity, healing, infection risk, recovery, patient factors, and the circumstances of the operation. Without directly comparable evidence for a specific setting, broad claims that one method is universally superior should be treated cautiously.

While glue (Dermabond) has been explored as an alternative to suture, the evidence remains less compelling. One RCT (n=107) found no significant difference in outcomes between glue and suture, while another (n=82) reported less pain in the glue arm during the first two weeks post-cesarean. However, these findings have not been consistently replicated, and the overall data supporting glue as a superior option is limited.

The Future of Cesarean Skin Closure

While absorbable suture remains the gold standard for skin closure in cesarean deliveries, ongoing research continues to explore potential alternatives. A recent study in BJOG compared absorbable staples to suture, finding similar incidences of wound complications and patient satisfaction. However, absorbable staples were associated with longer placement times and higher costs, suggesting that further research is needed before they can be considered a superior option. As technology advances and new materials become available, the future of cesarean skin closure may see further refinements. However, for the time being, absorbable suture remains the most reliable and evidence-based choice for optimizing patient outcomes and satisfaction.

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Evidence and Clinical Judgment

A balanced synthesis should distinguish established surgical practice from claims that remain dependent on patient or procedural factors. The choice of closure technique is best considered alongside the type of incision, operative conditions, and the patient's recovery needs. Expert judgment remains important when evidence does not establish a single best option for every cesarean birth.

Refining Cesarean Care

Future progress may focus on refining surgical techniques and perioperative care while preserving safety and reliable healing. Research may also clarify which closure approaches perform best for different patients and operative circumstances. Any emerging method will need evaluation against established outcomes rather than adoption based only on convenience or appearance.

A System-Level Procedure

Cesarean delivery affects more than the operating room because it is a major procedure performed within a broader system of obstetric care. Decisions may involve medical urgency, available resources, follow-up, recovery support, and patient preferences. Broader evaluation should therefore consider clinical outcomes alongside psychological and societal consequences.

Patient-Centered Recovery

For patients, cesarean birth involves both the delivery of a baby and recovery from abdominal surgery. The experience can shape physical recovery, emotional well-being, and confidence in the care received. Clear communication about the incision, closure, expected healing, and warning signs can help connect technical surgical decisions with real-world patient needs.

How reviews and guidance frame closure choices

A systematic review and meta-analysis focused on women with obesity included four studies and 2,038 participants: 984 received staples and 1,054 received subcuticular suture. Its authors said a larger meta-analysis was needed to confirm the findings, so the pooled evidence was not presented as definitive.[1]

A separate review of randomized trials comparing absorbable subcuticular suture with nonabsorbable metal staples reported shorter surgery duration with staples, while pain, cosmesis, and patient satisfaction appeared equivalent overall. This broader comparison adds outcomes beyond wound complications, but does not establish an advantage for either method on those measures.[2] [3]

NICE guidance says to consider sutures rather than staples to reduce superficial wound dehiscence. That recommendation addresses a specific wound outcome; it does not make the trial’s nonsignificant complication comparison statistically conclusive.[4] [5]

What comparisons still need clarification

  • Would a larger evidence synthesis confirm the findings for women with obesity, as the review itself calls for, or change the balance between staples and subcuticular suture?[1]

Terms used in cesarean closure evidence

Subcuticular suture
A closure method named in the trial and review comparisons.[2] [5]

Sources

  1. Staples versus subcuticular suture for cesarean skin closure in obese women: A systematic review and meta-analysis. (pubmed.ncbi.nlm.nih.gov)
  2. Suture Compared With Staples for Skin Closure After Cesarean Delivery: A Systematic Review and Meta-analysis. (pubmed.ncbi.nlm.nih.gov)
  3. Staples compared with subcuticular suture for skin closure after cesarean delivery: a systematic review and meta-analysis. (pubmed.ncbi.nlm.nih.gov)
  4. Recommendations | Caesarean birth | Guidance | NICE (www.nice.org.uk)
  5. Cesarean wound closure in body mass index 40 or greater comparing suture to staples: a randomized clinical trial. (pubmed.ncbi.nlm.nih.gov)

About this Article -

Written with AI assistance from published research, and reviewed by the Mystum team. See our About page for more information.

Everything You Need To Know

1

Why is absorbable suture considered the gold standard for skin closure in cesarean deliveries?

Absorbable suture is considered the gold standard for skin closure in cesarean deliveries due to its superior outcomes and patient satisfaction, as evidenced by numerous studies and meta-analyses. These studies, including a meta-analysis of 12 RCTs, have consistently demonstrated that suture closure leads to fewer wound complications, particularly wound separation, compared to methods like staples. Furthermore, suture closure results in improved cosmesis, meaning a more aesthetically pleasing scar appearance, and higher patient satisfaction levels. Current guidelines favor absorbable suture for skin closure because of this robust evidence base.

2

What are the key advantages of using absorbable suture over metal staples for cesarean skin closure?

The primary advantages of absorbable suture over metal staples for cesarean skin closure include a reduced risk of wound complications, better cosmetic outcomes, and increased patient satisfaction. Meta-analyses show lower rates of wound separation with suture closure, contributing to better healing. Suture closure also leads to more aesthetically pleasing scar appearance, which is a significant factor in patient satisfaction. Metal staples, while offering a quick closure method, often result in less desirable cosmetic outcomes and, in some studies, higher rates of complications compared to suture. These benefits of suture are well-documented through numerous randomized controlled trials (RCTs), making it the preferred method.

3

How does the use of glue (Dermabond) compare to absorbable suture in terms of outcomes after cesarean delivery?

The evidence for using glue (Dermabond) as an alternative to absorbable suture is less compelling. While one RCT (n=107) found no significant difference in outcomes between glue and suture, and another (n=82) reported less pain in the glue arm during the first two weeks post-cesarean, these findings have not been consistently replicated across different studies. The overall data supporting glue as a superior option is limited, and it does not provide the same level of evidence-based benefits as suture, especially regarding reduced wound complications and improved cosmesis. Thus, glue has not yet gained widespread acceptance as the preferred method for cesarean skin closure.

4

What are the potential future trends and alternatives to absorbable suture for cesarean skin closure?

While absorbable suture remains the gold standard, ongoing research explores potential alternatives. Absorbable staples have been studied, with a recent study in BJOG finding similar incidences of wound complications and patient satisfaction compared to suture. However, absorbable staples were associated with longer placement times and higher costs, indicating the need for more research before they can be considered superior. As technology advances, the future of cesarean skin closure may see further refinements with new materials and techniques, but for now, suture remains the most reliable and evidence-based choice for optimizing patient outcomes and satisfaction.

5

Why is patient satisfaction an important factor in choosing a skin closure method for cesarean delivery?

Patient satisfaction is a crucial factor in choosing a skin closure method for cesarean delivery because it reflects the overall experience and well-being of the patient, beyond just the clinical outcomes. Methods like absorbable suture not only lead to reduced wound complications but also improve cosmesis, resulting in more aesthetically pleasing scars. Studies show that women who undergo suture closure report higher levels of satisfaction with the aesthetic outcome of their scars compared to those who receive metal staples. This improved aesthetic outcome contributes to a better emotional and psychological recovery, enhancing the overall patient experience. Therefore, choosing a method that prioritizes both clinical effectiveness and patient satisfaction is essential in modern obstetrical practice.

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